1. Attending Physician: Resident/Fellow: 2. Consult
|
|
- Milo Tate
- 5 years ago
- Views:
Transcription
1 COLON POST OP PLAN A UMC Health System Performance Improvement Initiative for use in all units where surgical patients receive care in support of Surgical Care Improvement Program (SCIP). * Denotes guideline requirement for Core Measures Antibiotic administered in the OR at: 1. Attending Physician: Resident/Fellow: 2. Consult 3. Admit: ICU Other: Fall Precautions 4. Code Status: Full Code DNR Comfort Care Other: 5. Co-Morbidities: 6. Condition: Stable Fair Serious Critical 7. Allergies: NKDA Allergic to: 8. NURSING: Vital Signs: Routine post op VS per ICU Standards of Practice Notify MD for: Weight daily Intake and output: Hourly Every Shift Other: *FOLEY Foley Catheter Care Daily Urinary catheter/ suprapubic drain to gravity drainage Notify MD for urine output < 30 ml/hr * DC Foley at (POD #1) OR DC Foley at POD #2 Straight cath every 6 hrs prn, if unable to void Reinsert Foley catheter if straight cath required more than 2 times NG Care: NG to low intermittent suction; irrigate every 2 hours w 20 ml Normal Saline Diet: NPO Clear Liquids Full Liquids Mechanical Soft Regular Advance as tolerated Other Page 1 of 6 COLON Post- Op Plan
2 Activity: Head of Bed up degrees Turn, Cough, and Deep Breathe every hours for hours. Post Op Day: Treatment Bedrest Bathroom privileges Sit at side of bed Up to chair Up with assist Ambulate Shower Wash Hair Incision Care: Dressing change beginning: Post op: Day 1 Day 2 Day 3 Clean incision with: Betadine 4x4 gauze ABD Pad Alcohol CHG (Chlorhexidine Gluconate) Other: Re-enforce dressing prn with: ABD Pad 4x4 gauze Other: Incision open to air Post op: Day 1 Day 2 Day 3 Other: Remove Staples Post op: Day 1 Day 2 Day 3 Other: 9. LABORATORY/DIAGNOSTICS: (DO NOT REPEAT IF DONE IN THE EC UNLESS OTHERWISE INDICATED) CBC: Post op: Day 1 Day 2 Day 3 Notify Physician if: Basic metabolic profile: Post op: Day 1 Day 2 Day 3 Notify Physician if: Other: X-Ray: 10. RESPIRATORY THERAPY: 11. IV: Respiratory Care Program O liters/minute via SaO 2 Monitoring every hours - Discontinue oxygen therapy if SaO 2 consistently 92% or greater - O 2 saturations < 92% on room air; re check BID until > 92% on room air - Call physician if saturations continue at < 92% on room air Incentive Spirometer 10 times over 30 minutes, every hours when awake, until discharge Vent Settings: Mode FIO 2 Rate TV Peep ABG NOW Every AM Every 8 hours 1 hour after Vent changes Maintain saline lock INT for blood draws. Flush with NS q 4 hours and prn. Routine central line care and flushes Continuous IV fluids to run at ml/hr Page 2 of 6 COLON Post- Op Plan
3 12. MEDICATIONS: Refer also to Admission Medication Reconciliation Form & Discomfort orders *Antibiotic Therapy: *Antibiotic discontinued 24 hours after Anesthesia end time. (Select one of the following) Cefotetan Cefoxitin (Mefoxin) Ampicillin/Sulbactam (Unasyn) Cefuroxime + Metronidazole (Flagyl) Cefazolin (Ancef) + Metronidazole (Flagyl) IV IV β- lactam allergy: (Select one of the following) Clindamycin + Gentamycin Clindamycin + Levaquin Clindamycin + Aztreonam (Azactam) Metronidazole + Gentamicin Metronidazole + Levaquin IV IV Vancomycin mg IV (dc 24 hours post op) Therapeutic Antibiotic Antibiotic coverage ordered for greater than 24 hours post op, requires documentation of indication. Therapeutic Antibiotic: Reason antibiotic was continued or added greater than 24 hours post-operatively (48 hours for Coronary Artery Bypass Graft [CABG]): Must be documented by physician / advance practice nurse / physician assistant within 2 days (3 days for CABG or other cardiac surgery) following the principle procedure with the day of surgery being Day Zero. Abscess Acute abdomen Aspiration pneumonia Bloodstream infection Bone infection Cellulitis Endometritis Fecal Contamination Free air in abdomen Gangrene H. pylori Necrosis Necrotic/ischemic/infarcted bowel Osteomyelitis Other documented infection Penetrating abdominal trauma Perforation of bowel Pneumonia or other lung infection Purulence/pus Sepsis Surgical site or wound infection Urinary tract infection (UTI) (*Required if home medication) Beta Blocker: PO Unless contraindicated as listed here: (hold for SBP < _100 HR < _50 ) 13. PROPHYLAXIS: * VTE Prophylaxis: * Start within 24 hours of Anesthesia end time--pharmacologic in conjunction with Mechanical recommended *Start within 12 hrs. Post-operatively *Start within 24 hrs. Post-operatively Choose one of the following: Heparin 5000 units SQ BID every 8 hours Warfarin (Coumadin) PO every Enoxaparin (Lovenox): 30 mg SQ daily (Crcl < 30ml/min) 40 mg SQ daily Other: Page 3 of 6 COLON Post- Op Plan
4 Choose one of the following: SCDs Bilateral hours per day Plexi pulse (foot pumps) Bilateral hours per day TED Hose (thigh high) Bilateral hours per day Other: Reason for not administering venous thromboembolism prophylaxis: Must be documented by physician / advance practice nurse / physician assistant within 24 hours of Anesthesia end time. Bleeding risk Gastrointestinal bleed Hemorrhage Patient refusal Thrombocytopenia Excessive bleeding Active bleeding (gastrointestinal bleeding, cerebral hemorrhage, retroperitoneal bleeding) Patients on continuous IV Heparin therapy within 24 hours before or after surgery GI: Choose one of the following: Proton Pump Inhibitor: Esomeprazole (Nexium) 40 mg PO Daily H2 Blocker: Pepcid 20 mg PO BID Page 4 of 6 COLON Post- Op Plan
5 PATIENT DISCOMFORT MEDICATION PLAN Patient Label Here Indicate desired medications by checking appropriate box. If more than one box is checked for an indication, then use the ordered medications in the descending order. PAIN MANAGEMENT: (TARGET MAXIMUM OF 3000 MG OF ACETAMINOPHEN PER 24 HOURS FROM ALL SOURCES) (DO NOT EXCEED 4000MG OF ACETAMINOPHEN PER 24 HOURS) MILD PAIN (Pain Scale 1-3): Acetaminophen (Tylenol) mg PO every 4 hours PRN mild pain (Do not exceed 4,000 mg in 24 hours), if NPO use: Acetaminophen (Tylenol) 650 mg suppository PR every 4 hours PRN mild pain (Do not exceed 4,000 mg in 24 hours), if acetaminophen is ineffective/contraindicated use: Ibuprofen (Motrin) 400 mg PO every 6 hours PRN mild pain (Do not exceed 3,200 mg in 24 hours) MODERATE PAIN (Pain Scale 4-7): Hydrocodone/acetaminophen (Lortab) 5/500 mg 1 2 tabs PO every 4 hours PRN moderate pain (Do not exceed 4 grams of acetaminophen in 24 hours), if ineffective/contraindicated or NPO use: Ketorolac (Toradol) mg IV every 6 hours PRN moderate pain x 48 hours (May give IM if no IV access) Other SEVERE PAIN (Pain Scale 8-10): Morphine 2 4 mg slow IV push every 4 hours PRN severe pain, if ineffective/contraindicated use: Hydromorphone (Dilaudid) 1 mg slow IV push every 4 hours PRN severe pain NAUSEA/VOMITING: Promethazine (Phenergan) 25 mg PO every 4 hours PRN nausea/vomiting, if ineffective/contraindicated or NPO use: Ondansetron (Zofran) 4 mg IV every 8 hours PRN nausea/vomiting BOWEL MANAGEMENT: Docusate (Colace) 100 mg PO at bedtime PRN for constipation, if contraindicated or ineffective after 12 hours use: Bisacodyl (Dulcolax) 10 mg suppository PR daily PRN constipation, if contraindicated or ineffective after 6 hours use: Sodium phosphate enema (Fleet enema) PR daily PRN constipation (Do not use in renal patients) INDIGESTION/GAS: DIARRHEA: Aluminum hydroxide/magnesium hydroxide (Maalox) 30 ml PO every 4 hours PRN indigestion Simethicone (Mylicon) mg PO every 4 hours PRN gas/bloating Loperamide (Imodium) 4 mg PO initially then 2 mg PO with each loose stool (Max 16 mg hours) Page 5 of 6 COLON Post- Op Plan
6 Indicate desired medications by checking appropriate box. If more than one box is checked for an indication, then use the ordered medications in the descending order. ANXIETY: Alprazolam (Xanax) 0.25 mg PO three times a day PRN anxiety, if ineffective/contraindicated or NPO use: Lorazepam (Ativan) mg IV every 6 hours PRN anxiety _ SLEEPLESSNESS: Zolpidem (Ambien) 5 mg PO at bedtime PRN sleeplessness, may repeat x 1 in one hour if ineffective _ ALLERGIC REACTIONS: Diphenhydramine (Benadryl) 25 mg PO every 4 hours PRN itching, if ineffective or NPO use: Diphenhydramine (Benadryl) 25 mg IV every 4 hours PRN itching _ COUGH / SORE THROAT: Phenol-menthol (Cepastat) 1 lozenge PO PRN sore throat (Do not exceed 6 lozenges in 24 hours) Guaifenesin/dextromethorphan (Robitussin DM) 10 ml PO every 4 hours PRN cough _ TEMPERATURE: Acetaminophen (Tylenol) mg PO every 4 hours PRN fever (Do not exceed 4,000 mg in 24 hours), if ineffective/contraindicated use: Ibuprofen (Motrin) mg PO every 4 hours PRN fever (Do not exceed 3,200 mg in 24 hours) _ HEMORRHOIDS: MUCOSITIS: Witch hazel/glycerin (Tucks) pads at bedside wipe affected area as PRN, if ineffective use: Mineral oil/petrolatum/phenylephrine (Preparation H) ointment apply to affected area every 6 hours PRN. If ineffective/contraindicated use: Pramoxine/hydrocortisone (Proctofoam HC) at bedside apply to affected area every 8 hours PRN Dexamethasone/diphenhydramine/nystatin/NS (Fred s Brew) 15 ml swish and spit every 2 hours while awake PRN. mucositis. If ineffective/contraindicated use: Viscous lidocaine (Xylocaine) 15 ml swish and spit every 4 hours PRN mucositis BLADDER SCAN: Bladder scan as needed for patients complaining of urinary discomfort and/or bladder distention present OR 6 hours post-foley removal and patient has not voided. If bladder scan volume is >250 ml please notify the physician. OTHER: Page 6 of 6 COLON Post- Op Plan
A UMC Health System Performance Improvement Initiative for use in all units where patients with are admitted for Surgical Care Improvement Project.
ENDOLUMINAL AAA POST-OP PLAN A UMC Health System Performance Improvement Initiative for use in all units where patients with are admitted for Surgical Care Improvement Project. *Denotes guideline requirement
More informationProcedure: Laser Transurethral Resection of Prostate or Transurethral Resection of Prostate
Laser Transurethral Resection Of Prostate Or Transurethral Resection Of Prostate Post-Operative Plan Patient Label Here A UMC Health System Performance Improvement Initiative for use in all units where
More information1. Attending Physician: Resident/Fellow: 2. Admit: MEDICAL/SURGICAL ICU Other: Designation: In Patient Out Patient. 5.
UROLOGY POST OPERATIVE PLAN Patient Label Here A UMC Health System Performance Improvement Initiative for use in all units where surgical patients receive care in support of Surgical Care Improvement Program
More information1. Attending Physician: Dr Syn Pager: Cell: Co-Morbidities:
BARIATRIC SURGERY IMMEDIATE POST-OP PLAN (Includes Post Op Day 1) Denotes order requirement Antibiotic administered in the OR at: 1. Attending Physician: Dr Syn Pager: 740-6545 Cell: 438-9415 2. To remain
More informationmorphine 30 mg/ 30 ml (1 mg/ml) Opioid of choice
PATIENT CONTROLLED ANALGESIA (PCA) PLAN Allergies: Medication Selection: morphine 30 mg/ 30 ml (1 mg/ml) Opioid of choice HYDROmorphone (Dilaudid ) 6 mg/ 30 ml (0.2 mg/ml) fentanyl 300 mcg/ 30 ml (10 mcg/ml)
More informationA UMC Health System Performance Improvement Initiative for use in all units where cardiac/surgical patients are admitted.
A UMC Health System Performance Improvement Initiative for use in all units where cardiac/surgical patients are admitted Denotes guideline requirement Attending Physician: Resident/Fellow: Allergies_ Diagnosis:
More informationPatient Label Here. ORTHOPEDIC POST-OPERATIVE ADMIT PLAN (Includes Post Op Days 1-2) Antibiotic administered in the OR at:
ORTHOPEDIC POST-OPERATIVE ADMIT PLAN (Includes Post Op Days 1-2) A UMC Health System Performance Improvement Initiative for use in all units where surgical patients receive care in support of Surgical
More informationPatient Label Here CAROTID POST OP PLAN. Antibiotic administered in the OR at: Physician Signature Date/Time
CAROTID POST OP PLAN A UMC Health System Performance Improvement Initiative for use in all units where patients with carotid surgery are admitted in support of the Surgical Care Improvement Program (SCIP).
More informationENT THYROIDECTOMY/PARATHYROIDECTOMY POST OP PLAN - Phase: Begin Immediately/PACU
- Phase: Begin Immediately/PACU PHYSICIAN S Diagnosis Weight Allergies Laboratory Calcium Level STAT Outpatient/PACU, T;N PTH Intact STAT Outpatient/PACU, T;N 1 of 7 - Phase: When Patient Arrives to Room
More informationGENERAL SURGERY POST-OP PLAN
GENERAL SURGERY POST-OP PLAN PHYSICIAN S Diagnosis Weight Allergies Patient Care Vital Signs Per Unit Standards Patient Activity Up Ad Lib/Activity as Tolerated Assist as Needed Bedrest Bedrest Bathroom
More informationOB/GYN POSTPARTUM VAGINAL DELIVERY PLAN
OB/GYN POSTPARTUM VAGINAL DELIVERY PLAN PHYSICIAN S Diagnosis Weight Allergies Patient Care Vital Signs Per Unit Standards Patient Activity Up Ad Lib/Activity as Tolerated Bedrest STRICT Bedrest Up to
More informationENT THYROIDECTOMY/PARATHYROIDECTOMY POST OP ADMIT PLAN - Phase: Begin Immediately/PACU
- Phase: Begin Immediately/PACU Diagnosis Weight Allergies DETAILS Admit/Discharge/Transfer Patient Status Pt Status: Inpatient (LOS > 2 midnights) Pt Status: Observation (LOS < 2 midnights) Pt Status:
More informationEPIDURAL / INTRATHECAL POST-OP PLAN
EPIDURAL / INTRATHECAL POST-OP PLAN Diagnosis Weight PHYSICIAN S Allergies Patient Care Vital Signs Per Unit Standards, PLUS check and record RR q1h x 12, then q2h x 6, until 24h following narcotic administration.
More informationGENERAL SURGERY PLAN - Phase:.
- Phase:. PHYSICIAN S Diagnosis Weight Allergies Patient Care Vital Signs Per Unit Standards Daily Weight Patient Activity Up Ad Lib/Activity as Tolerated Assist as Needed Bedrest Bedrest Bathroom Privileges
More informationOB/GYN POSTPARTUM VAGINAL DELIVERY PLAN
OB/GYN POSTPARTUM VAGINAL DELIVERY PLAN PHYSICIAN S Diagnosis Weight Allergies DETAILS Admit/Discharge/Transfer Patient Discharge Anticipated in 24 Hour (Patient Discharge Anticipated in 24 Hours) Patient
More informationLYSIS OF ADHESIONS POST-OP PLAN - Phase: PACU Phase
- Phase: PACU Phase PHYSICIAN S Diagnosis Weight Allergies Communication Place Device at Bedside Confirm there are 3 x Aliquots of 0.2% Ropivacaine. 2 x Medfusion Infusion pumps. Confirm 3 x PF Aliquots
More informationUMC Health System Patient Label Here. PHYSICIAN ORDERS Diagnosis
COPD PLAN UMC Health System PHYSICIAN S Diagnosis Weight Allergies DETAILS Patient Care Vital Signs Per Unit Standards Daily Weight Patient Activity Up Ad Lib/Activity as Tolerated Assist as Needed Bedrest
More informationADMIT GENERAL MEDICINE PLAN - Phase: Begin Immediately
- Phase: Begin Immediately Weight PHYSICIAN S Allergies Admit/Discharge/Transfer Patient Status Patient Condition Acuity Level Floor Status Acuity Level Critical Acuity Level Intermediate Continuous Telemetry
More informationGENERAL MEDICINE PLAN
GENERAL MEDICINE PLAN PHYSICIAN S Diagnosis Weight Allergies Patient Care Vital Signs Per Unit Standards Daily Weight Patient Activity Up Ad Lib/Activity as Tolerated Assist as Needed Bedrest Bedrest Bathroom
More information(Page 1 of 5) Diagnosis: Procedure: Right Total Knee Replacement Unicompartmental Knee Left Total Hip Revision Total Shoulder
(Page 1 of 5) Allergies/Sensitivities/Reactions: Height: Inches cm Weight: Kg Pounds = Automatic = Physician s option, Check off to Order Diagnosis: Procedure: Right Total Knee Replacement Unicompartmental
More informationPHYSICIAN ORDERS Diagnosis
GENERAL UROLOGY PLAN PHYSICIAN S Diagnosis Weight Allergies Patient Care Vital Signs Per Unit Standards Strict Intake and Output Per Unit Standards q4h q12h Patient Activity Assist as Needed Up in Chair,
More informationOB/GYN ANTEPARTUM PLAN
OB/GYN ANTEPARTUM PLAN PHYSICIAN S Diagnosis Weight Allergies Patient Care Vital Signs Per Unit Standards Patient Activity Up Ad Lib/Activity as Tolerated Bedrest STRICT Bedrest Up to Bedside Commode Only
More informationOB/GYN CESAREAN SECTION POST-OP PLAN - Phase: General Orders
- Phase: General Orders DETAILS Patient Care Vital Signs Per Unit Standards Patient Activity Up Ad Lib/Activity as Tolerated Assist as Needed Bedrest Bedrest Bathroom Privileges Bedrest Up to Bedside Commode
More informationTHROMBOLYTIC THERAPY FOR PERIPHERAL OCCLUSION
THROMBOLYTIC THERAPY FOR PERIPHERAL OCCLUSION PHYSICIAN S Diagnosis Weight Allergies Admit/Discharge/Transfer ***PROVIDER MUST CHECK MEDICATION LIST PRIOR TO PLACING THESE S*** Patient Care Vital Signs
More informationHip Hemiarthroplasty Post Op Version 2 4/20/17
Patient Name: Diagnosis: Allergies with reaction type: Hip Hemiarthroplasty Post Op Version 2 4/20/17 Patient Placement General Diagnosis/Procedure: Preferred Location/Unit Ortho/Neuro PCU ICU General
More informationInitials * Page 1 of 6. (place patient label here) Patient Name: Diagnosis: Allergies with reaction type:
Patient Name: Diagnosis: Allergies with reaction type: Orthopedic Upper Ext Post Op Version 3 4/20/17 Patient Placement General Diagnosis/Procedure: Preferred Location/Unit Ortho/Neuro General Medical
More informationGENERAL SURGERY POST OP ORDERS. Admit to floor to Dr. l Inpatient l Observation l Telemetry
Check appropriate boxes: ** Admit to floor to Dr. l Inpatient l Observation l Telemetry Diagnosis: Consult Dr. Reason: l I have called Dr., add to his/her list. Diet: l NPO l Regular NURSING ERS: Activity:
More informationAdmit Heart Failure Plan - Begin Immediately
Admit Heart Failure Plan - Begin Immediately Diagnosis Weight PHYSICIAN S Allergies Admit/Discharge/Transfer Patient Status Requested Location: CICU, Pt Status: Observation (LOS < 2 midnights) Requested
More informationUMC Health System Patient Label Here. PHYSICIAN ORDERS Diagnosis
GI BLEED PLAN UMC Health System Diagnosis Weight Allergies Patient Care Vital Signs Per Unit Standards Notify Provider of VS Parameters Daily Weight Patient Activity Up Ad Lib/Activity as Tolerated Assist
More informationST. DOMINIC-JACKSON MEMORIAL HOSPITAL JACKSON, MISSISSIPPI
Date & Time Post-Op Inpatient General Orthopedic Page 1 of 5 Pharmacy Mnemonic: POIGOP1 1. Admit as inpatient to Dr. 2.Diagnosis: 3.Admit to PACU and then to floor ICU 4.Radiology: AP Pelvis in PACU AP
More informationTRANSCATHETER AORTIC VALVE REPLACEMENT POST- OP PLAN - Phase:.
- Phase:. PHYSICIAN S Diagnosis Weight Allergies DETAILS Patient Care Vital Signs Per Unit Standards, q15min x 4, q30min x 2, then q1h x 4 until sheath discontinued. Per Unit Standards Perform Neurovascular
More informationTotal Hip Replacement Post Op Version 4 4/20/17
Patient Name: Diagnosis: Allergies with reaction type: Total Hip Replacement Post Op Version 4 4/20/17 Patient Placement General Diagnosis/Procedure: Preferred Location/Unit Ortho/Neuro General Medical
More informationPEDIATRIC SPINE SURGERY POST-OP PLAN - Phase:.
- Phase:. PHYSICIAN S Diagnosis Weight Allergies DETAILS Patient Care Patient Activity Bedrest Maintain Surgical Drain Maintain JP Drain, Measure Output q12h, and PRN Convert IV to INT when tolerating
More informationWHS POSTOPERATIVE POWERPLAN CHANGES
Medications simplified and standardized to improve safety and effectiveness in the management of pain, itching, nausea/vomiting. Management: o The Anesthesiologist will continue to manage pain in the PACU.
More informationTRANSCATHETER AORTIC VALVE REPLACEMENT POST- OP ADMIT PLAN - Phase: Begin Immediately/PACU Phase
- Phase: Begin Immediately/PACU Phase PHYSICIAN S Diagnosis Weight Allergies DETAILS Admit/Discharge/Transfer Patient Status Requested Location: CICU Patient Condition Acuity Level Critical Acuity Level
More informationPEDIATRIC SPINE SURGERY POST-OP PLAN - Phase: Pediatric Spine Surgery General Orders
- Phase: Pediatric Spine Surgery General Orders PHYSICIAN S Diagnosis Weight Allergies Patient Care Patient Activity Bedrest Maintain Surgical Drain Maintain JP Drain, Measure Output q12h, and PRN Convert
More information1 of 5. Integrated Order Set Inpatient, Adult. Gynecological Surgery Enhanced Recovery Orders apply to patients 18 years and older.
Orders apply to patients 18 years and older. All preprinted doses are based on normal renal and hepatic function and must be assessed for adjustment against the individual patient s renal and hepatic function
More informationBariatric Surgery Post Op Day Version 2 Approved 11/13/2017
Patient Name: Diagnosis: Allergies with reaction type: Bariatric Surgery Post Op Day Version 2 Approved 11/13/2017 Diagnosis Preferred Location/Unit Surgical ICU Code Status: Full Code Activity Ambulate
More informationOrthopedic Admission Hip Fracture Version 2 1/25/2017
Patient Name: Initial each page and Sign/Date/Time last page Diagnosis: Allergies with reaction type: Orthopedic Admission Hip Fracture Version 2 1/25/2017 Patient Placement Patient Status If the physician
More informationTRAUMA AND SURGICAL ICU PLAN
TRAUMA AND SURGICAL ICU PLAN PHYSICIAN S Diagnosis Weight Allergies DETAILS Patient Care Vital Signs Per Unit Standards Daily Weight Insert Peripheral Line Patient Activity Bedrest, Bed Position: HOB Greater
More informationADMIT CHEST PAIN PLAN - Phase: Begin Immediately
- Phase: Begin Immediately PHYSICIAN S Diagnosis Weight Allergies Admit/Discharge/Transfer Patient Status Requested Location: CICU, Pt Status: Observation (LOS < 2 midnights) Requested Location: 5E / IMCU,
More informationIV Acetaminophen Pain Study for Neurosurgery Post Op Non ICU Admit Plan Begin Immediately/PACU
Post Op Non ICU Admit Plan Begin Immediately/PACU PHYSICIAN S Weight Allergies Admit/Discharge/Transfer Request Patient Bed Requested Location: 3W, Pt Status: Inpatient (LOS > 2 midnights) Patient Condition
More informationISCHEMIC STROKE/TIA PLAN
ISCHEMIC STROKE/TIA PLAN PHYSICIAN S Weight Allergies DETAILS Admit/Discharge/Transfer Patient Status Pt Status: Inpatient (LOS > 2 midnights) Pt Status: Observation (LOS < 2 midnights) Code Status Code
More informationISCHEMIC STROKE/TIA PLAN
ISCHEMIC STROKE/TIA PLAN PHYSICIAN S Diagnosis Weight Allergies Patient Care Vital Signs Per Unit Standards, Every 15 min x 2 hrs; then every 30 min x 6 hrs; then every 1 hr x 16 hrs Perform Neurological
More informationUMC Health System Patient Label Here PHYSICIAN ORDERS
Dx Weight PHYSICIAN S Allergies DETAILS Admit/Discharge/Transfer Patient Status Pt Status: Inpatient (LOS > 2 midnights) Pt Status: Observation (LOS < 2 midnights) Code Status Code Status: Full Code Code
More informationSTROKE NEUROINTERVENTION PLAN - Phase:.
- Phase:. PHYSICIAN S Diagnosis Weight Allergies Patient Care Vital Signs Per Unit Standards Notify Nurse (DO NOT USE FOR MEDS) Right Lower Extremity-Check peripheral pulse distal to the cath site. If
More informationADMIT STROKE NEUROINTERVENTION PLAN - Phase: Begin Immediately
- Phase: Begin Immediately PHYSICIAN S Diagnosis Weight Allergies DETAILS Admit/Discharge/Transfer Patient Status Pt Status: Inpatient (LOS > 2 midnights) Pt Status: Observation (LOS < 2 midnights) Pt
More informationCARD POST CARDIAC CATHETERIZATION PLAN
CARD POST CARDIAC CATHETERIZATION PLAN Diagnosis Weight PHYSICIAN S Allergies DETAILS Patient Care Intermittent Telemetry Continuous Telemetry (Intermediate Care) Vital Signs Per Unit Standards POC ACT
More informationOPEN AAA/MAJOR ABDOMINAL POST-OP PLAN - Phase:.
- Phase:. PHYSICIAN S Diagnosis Weight Allergies Patient Care Vital Signs Per Unit Standards Maintain Gastric Tube Maintain Nasogastric - NG, Low Intermittent Suction Maintain Nasogastric - NG, Low Constant
More informationSample. Fractured Hip Post-Operative Orders. Legend < Mandatory fields o Optional fields. Height Allergies: List or o Up to date in electronic system
Legend Mandatory fields o Optional fields Height Allergies: List or o Up to date in electronic system cm Weight Diagnosis kg Date (yyyy-mon-dd) Time (hh:mm) Anticipated Date Of Discharge (ADOD) o Greater
More informationr*po1004*r PHYSICIAN S ORDERS Page 1 of 7 HOUR THORACOTOMY POSTOPERATIVE ORDERS General x Admit to Inpatient Status x Admitting Physician: Admit to:
PHYSICIAN S ORDERS Page 1 of 7 General x Admit to Inpatient Status x Admitting Physician: Admit to: SICU Telemetry Med/Surg room x Resuscitation status: see Resuscitation Status Order Activity x Bed rest
More informationPhysician Orders PEDIATRIC: LEB Oral Maxillofacial Post Op Plan
Initiate Orders Phase Care Sets/Protocols/PowerPlans Initiate Powerplan Phase Phase: LEB Oral Maxillofacial Postop Phase, When to Initiate: LEB Oral Maxillofacial Post Op Phase Admission/Transfer/Discharge
More informationCARD POST CARDIAC CATHETERIZATION PLAN
CARD POST CARDIAC CATHETERIZATION PLAN PHYSICIAN S Diagnosis Weight Allergies Patient Care Intermittent Telemetry Continuous Telemetry (Intermediate Care) Vital Signs Per Unit Standards POC ACT If arterial
More informationAdmit date (YYYY/MM/DD): Cardiologist On-Call: Diagnosis: Lab Tests. CBC, Electrolytes, Urea, Creatinine, Glucose, INR, PTT, Urinalysis
of nurse 1. Admit under ward Attending Physician: Dr. Admit date (YYYY/MM/DD): Cardiologist On-Call: Diagnosis: Lab Tests 2. On admission (if not already performed in Emergency Department or in Coronary
More informationORTHO TOTAL KNEE REPLACEMENT POST-OP PLAN - Phase: PACU Ortho Phase
- Phase: PACU Ortho Phase PHYSICIAN S Diagnosis Weight Allergies DETAILS Admit/Discharge/Transfer Patient Status Patient Condition Acuity Level Floor Status Acuity Level Critical Acuity Level Intermediate
More informationPhysician's Core Measure Pocket Guide AMI
Physician's Core Measure Pocket Guide Core Measure Hotline: Ext. 4448 http://centegramedsource.com Indicator: AMI AMI VER. 9/2018 MUST document WHY no ASA unless there is documentation of contraindication
More informationStandardized Nurse Activated Protocols (SNAPs)
SNAPs by presenting complaint/problem help nurses initiate care before the patient is seen by a physician. SNAPs should be approved by ED team consensus If patient unstable in any way, immediately notify
More informationSEPSIS PLAN - Phase:.
- Phase:. UMC Health System PHYSICIAN S Diagnosis Weight Allergies Patient Care Vital Signs Per Unit Standards Patient Activity Bedrest Bedrest Bathroom Privileges Bedrest Up to Bedside Commode Only Up
More informationUMC Health System Patient Label Here. PHYSICIAN ORDERS Diagnosis
CHEST PAIN PLAN UMC Health System PHYSICIAN S Diagnosis Weight Allergies Patient Care Vital Signs Per Unit Standards Daily Weight Patient Activity Up Ad Lib/Activity as Tolerated Assist as Needed Bedrest
More informationUNIVERSITY OF CALIFORNIA, DAVIS MEDICAL CENTER SACRAMENTO, CALIFORNIA
ENT ADMISSION ORDERS TO TOWER 7 MSICU Attending: Fellow: Resident: Diagnosis: Surgery: Isolation: Allergies: (Food & Med.) Respiratory Settings: FiO2 SIMV TV PS PEEP. O2 Therapy L, %, NP Mask Cupula Heated
More informationGENERAL SURGICAL ADULT POST-OPERATIVE ORDERS 1 of 4
down ADULT POST-OPERATIVE 1 of 4 9 Actual 9 Estimated Patient ID Area Weight kg 9 Actual 9 Estimated Height cm ALLERGIES: REFER TO ALLERGY PROFILE/ POWERCHART Admit to: Post Anesthesia Care Unit (PACU),
More informationGeneral. Code Status (Single Response) ( ) Full Code Details ( ) Full code - unverified Details ( ) DNRCC Allow additional therapies?
Post Operative Above and Below Knee Amputation Admission [3041300028] Consider adding Insulin Adult -- Subcutaneous Insulin and Hypoglycemia Management [3041300000] General Admission (Single Response)
More information* * FORM REV. 02/2019 Page 1 of 4. TNKASE (tenecteplase) / ACUTE STEMI ORDERS SCHEDULED MEDICATIONS:
1. Is this a CMS inpatient only procedure? Yes, admit as inpatient, proceed to # 3 No, proceed to # 2 2. Do you expect that the patient s condition will require a hospital stay that will cross two midnights
More informationPhysician s Order Form. Physician s Order Form. Telemetry/Progressive Care Orders. Continued on next page. >>>>>>> Continued on next page.
DATE: TIME: DATE TIME INTRAVENOS FLID and MEDICATION Status: Admit to Telemetry Admit to Progressive Care nit Transfer to Progressive Care nit Note: Discontinue Previous Orders Transfer to Telemetry nit
More informationPhysician Orders ADULT: Kidney-Panc/PancTransplant Post Op Plan
Initiate Orders Phase Care Sets/Protocols/PowerPlans Initiate Powerplan Phase T;N, Phase: Kidney-Panc/Panc Transp Post Op Phase, When to Initiate: Kidney-Panc/Panc Transp Post Op Phase Vital Signs Vital
More informationIDPH ESF-8 Plan: Pediatric and Neonatal Surge Annex Sample Pediatric Admission Orders 2015
Purpose: To provide guidance to practitioners caring for pediatric patients who need inpatient hospital care during a disaster. Disclaimer: This guideline is not meant to be all inclusive, replace an existing
More informationPediatric Outpatient Surgery Plan - Diagnostic/Pre-Op Orders
Pediatric Outpatient Surgery Plan - Diagnostic/Pre-Op Orders Diagnosis Weight PHYSICIAN S Allergies Admit/Discharge/Transfer Request for Outpatient Services Location: Outpatient Surgery Communication Misc
More informationADMIT DIABETIC KETOACIDOSIS (DKA) PLAN - Phase: Begin Immediately/Emergency Center
- Phase: Begin Immediately/Emergency Center Weight PHYSICIAN S Allergies Admit/Discharge/Transfer Patient Status Requested Location: MICU, Pt Status: Inpatient (LOS > 2 midnights) Requested Location: 5E
More informationGabapentin Research Pain Study for Ortho Total Knee Replacement Post-Op Plan - PACU Ortho Phase
Total Knee Replacement Post-Op Plan - PACU Ortho Phase Diagnosis Weight Allergies Admit/Discharge/Transfer Patient Status Requested Location: 3W, Pt Status: Inpatient (LOS > 2 midnights) Patient Condition
More informationBariatric Surgery Post Op Plan PACU Phase
Bariatric Surgery Post Op Plan PACU Phase PHYSICIAN S Weight Allergies Admit/Discharge/Transfer Patient Status Pt Status: Inpatient (LOS > 2 midnights) Pt Status: Observation (LOS < 2 midnights) Code Status
More informationPresentation at ACS NSQIP National Conference in July Surgical Site Infection Reduction Strategies
Presentation at ACS NSQIP National Conference in July 2015 Surgical Site Infection Reduction Strategies PeaceHealth Sacred Heart Medical Center at RiverBend Level II Trauma Center 379 Beds 15,060 cases
More informationLONG TERM CARE FACILITY ADMIT ORDERS
Page 1 of 7 LONG TERM CARE FACILITY ADMIT ORDERS ADMISSION: Admit patient to Skilled Nursing Facility: Admit patient to Acute Rehabilitation Facility: Admit patient to Subacute Rehabilitation Facility:
More informationQuality Improvement Updates Foley Discontinuation Protocol Surgical Care Improvement Project
Quality Improvement Updates Foley Discontinuation Protocol Surgical Care Improvement Project Barbara J Martin, RN, MBA Quality Consultant, Center for Clinical Improvement Indwelling Urinary Catheters Insertion,
More informationIR Central Venous Access [ ] Pre Procedure
IR Central Venous Access [1050200001] Pre Procedure Case Request/Scheduling Procedure Enter IR Case Request if not already completed (All hospitals except Grant Medical Center) [ ] Case Request IR Lab
More informationAttach patient label here. Physician Orders ADULT: Palliative Care Plan
Initiate Orders Phase Care Sets/Protocols/PowerPlans Initiate Powerplan Phase T;N, Phase: Palliative Care Phase, When to Initiate: Palliative Care Phase Admission/Transfer/Discharge Patient Status Initial
More informationPhysician Orders ADULT: Head and Neck Postoperative Plan
Initiate Orders Phase Care Sets/Protocols/PowerPlans Initiate Powerplan Phase, Phase: Head and Neck Postoperative Phase, When to Initiate: Head and Neck Post Operative Phase, Monitor and Record T,P,R,BP,
More informationCARD THORACOTOMY PRE-OP PLAN
CARD THORACOTOMY PRE-OP PLAN PHYSICIAN S Diagnosis Weight Allergies Patient Care Perform Oral Care Perform night before surgery. Brush teeth with toothpaste, then swish and spit 15 ml chlorhexidine mouth
More informationPOST-OP CARDIAC SURGERY PHYSICIAN S ORDER SHEET USE BALLPOINT PEN ONLY. CARDIAC INTENSIVE CARE UNIT
PHYSICIAN S SHEET Automatically Activate, if not in agreement, cross out and initial Activated by Checking Box ALLERGIES: None known YES Patient s Height: Patient s Weight: ALL MEDICATION and INTRAVENOUS
More informationPICU ADMIT DKA PLAN - Phase: Begin Immediately
- Phase: Begin Immediately Diagnosis Weight Allergies Admit/Discharge/Transfer Patient Status Requested Location: PICU, Pt Status: Inpatient (LOS > 2 midnights) Requested Location: PICU, Pt Status: Observation
More informationAssessment. Consults & Referrals
University of Virginia Health System Clinical Pathway: Whipple Enhanced Recovery After () LOS: 4-5 days Date of Origin/Revision: June 29, 2016/September 6, 2017/January 31, 2018 : SAS : : : D1 D2 D 3/
More informationCARD OPEN HEART PRE-OP PLAN
PHYSICIAN S Diagnosis Weight Allergies Patient Care Perform Oral Care Per Unit Standards, Perform night before surgery. Brush teeth with toothpaste. Peridex mouth wash (15 ml swish and spit). chlorhexidine
More informationPhysician Orders PEDIATRIC: LEB NEURO SURG Surgical Spine Post Op Plan
Initiate Orders Phase Care Sets/Protocols/PowerPlans Initiate Powerplan Phase Phase: LEB Neuro Surg Spine Postop Phase, When to Initiate: LEB Neuro Surgical Spine Post Op Phase Admission/Transfer/Discharge
More informationPhysician Orders ADULT
Admission Height (Actual) : cm Admission Weight (Actual): kg Allergies: No known allergies Medication allergy(s): Latex allergy Other: Non-Categorized ATTENTION SURGEON: Please discontinue Open Heart Post
More informationADULT TRANSCATHETER AORTIC VALVE REPLACEMENT (TAVR) TELEMETRY BED TRANSFER ORDERS 1 of 4
TELEMETRY BED TRANSFER 1 of 4 9 Actual 9 Estimated Patient ID Area Weight kg 9 Actual 9 Estimated Height cm ALLERGIES: REFER TO ALLERGY PROFILE/ POWERCHART Transfer to: 10 South Attending Physician: Diagnosis:
More informationUSD Healthcare Center
Sally Nelson DOB: 11/29/1941 HCP: Dr. Winters Age: 68 yrs. Height: 67 in. (170 cm) Weight: 145 lbs. (65.9 kg.) MR# PCS62800 Gender: F No Known Allergies Allergies & Sensitivities PCN, Sulfa Diagnosis:
More information(30689) PROT Pain PCA Adult Patient Controlled Analgesia
Diagnosis Allergies Nursing Assess and Document PCA: 1. Assess and document pain rating, sedation level and respiratory rate every 2 hours; assess and document pain rating, sedation level and respiratory
More informationPhysician Orders PEDIATRIC: LEB Kidney Transplant Post Op Plan
Initiate Orders Phase Care Sets/Protocols/PowerPlans Initiate Powerplan Phase Phase: LEB Kidney Transplant Post Op Phase, When to Initiate: LEB Kidney Transplant Post Op Phase Admission/Transfer/Discharge
More informationSPINE ORTHOPAEDIC SURGERY POST-OPERATIVE ORDERS 1 of 5
9 Actual 9 Estimated DOWNTIME POST-OPERATIVE 1 of 5 Weight kg 9 Actual 9 Estimated Height cm ALLERGIES: REFER TO ALLERGY PROFILE/ POWERCHART Admit to Service: Admit to: Post Anesthesia Care Unit (PACU)
More informationPHYSICIAN SIGNATURE DATE TIME DRUG ALLERGIES WT: KG
DRUG AND TREATMENT PACE Vital Signs Vital Signs PRE-OP, On arrival Nursing Orders Initiate ANES Anesthesia PACE PowerPlan Weigh Patient PRE-OP Pre op. Provide patient with incentive spirometry teaching
More informationThe Surgical Patient. Objectives:
The Surgical Patient Objectives: 1. Discuss the effect of surgery on the body systems. 2. Explain the etiological factors, nursing assessment, and management of potential problems during the postoperative
More informationAbdominoplasty Pre-op and Post-Op Instructions
Abdominoplasty Pre-op and Post-Op Instructions Pre-Op Instructions: * Stop all aspirin products, female hormones (including BCP s) and herbal medications 10 days prior to surgery. Vitamins in standard
More informationPHYSICIAN SIGNATURE DATE TIME DRUG ALLERGIES WT: KG
DRUG AND TREATMENT Available at: ALL Adult Facilities Non Categorized SUB ED Abdominal Pain Protocol(SUB)* ***The above subphase is available at the end of the plan*** SUB ED Abdominal Pain Protocol Lab
More informationProof 2. CLINICAL PATHWAY PLAN CLINIQUE GENERAL SURGERY CHIRURGIE GÉNÉRAL Enhanced Recovery After Surgery (ERAS) Bowel Surgery /
CLINICAL PATHWAY PLAN CLINIQUE GENERAL SURGERY CHIRURGIE GÉNÉRAL Enhanced Recovery After Surgery (ERAS) Bowel Surgery / Proof 2 Addressograph/Plaque Cancer Assessment Clinic (CAC) Date: yyaa mm dj Day
More informationNeurosurgery Pre-Op [1710] Patient Name MRN. General. Nursing. Case Request [ ] Case request operating room Scheduling/ADT, Scheduling/ADT [ ] Other
Neurosurgery Pre-Op [1710] Patient Name MRN General Case Request [ ] Case request operating room Scheduling/ADT, Scheduling/ADT Inpatient Only Procedure (Single Response) ( ) Admit to Inpatient Diagnosis:
More informationPhysician Orders PEDIATRIC: LEB Ortho Accelerated Posterior Spinal Fusion Post Op Plan
Initiate Orders Phase Care Sets/Protocols/PowerPlans Initiate Powerplan Phase Phase: LEB Ortho Accelerated PSF Post Op Initial Phase, When to Initiate: Initiate Powerplan Phase Phase: LEB Ortho Accelerated
More informationPHYSICIAN SIGNATURE DATE TIME DRUG ALLERGIES WT: KG
DRUG AND TREATMENT Available ONLY at: BMC-B BMC-D BMC-N BMC-S PACE Nursing Orders ***NOTE*** Select the "Transfuse Blood Previously on Hold" order below, to transfuse blood on hold. Transfuse Blood Previously
More informationSevere β-lactam allergy. Alternative (use for mild-moderate β-lactam allergy) therapy
Recommended Empirical Antibiotic Regimens for MICU Patients Notes: The antibiotic regimens shown are general guidelines and should not replace clinical judgment. Always assess for antibiotic allergies.
More informationIF YOU RECEIVED THIS FACSIMILE IN ERROR, PLEASE CALL IMMEDIATELY. ADMISSION INSTRUCTIONS: Admitted to Dr.
ADMISSION INSTRUCTIONS: Admitted to Dr. Procedure: Right Hip Left Hip CODE STATUS: Full DNR level of intervention DIET: Dysphagia screen consult SLP High protein, high energy Regular Nutrient dense Boost
More informationAllergies: Weight: kg Diagnosis: Procedure Performed Describe Procedure:
Page 1 of 11 Allergies: Weight: kg Diagnosis: Service: Admission Admit to Inpatient Admit to Daypatient Place on Outpatient Observation Status Hospital Attending: Attending Physician Attending Provider:
More informationManagement of elective cervical and lumbar spine surgery candidates age 18 years and older.
IMPORTANCE OF FOCUS According to the Spine Journal (2009), projections based on national health expenditure for spine surgery indicate spine surgical procedures/revisions are expected to grow significantly
More information